anwenderbericht

Long-term study on immediate

­loading of one-piece KOS® implants
with fixed complete dentures
Success of 678 one-piece KOS implants up to 9 years after
­transgingival placement without navigation
The past three decades have seen the treatment concept of dental implantology evolve into a standard
treatment regimen. Brånemark developed a two-stage procedure that relied on two-piece implants.
Over the past few years, practitioners have followed in the footsteps of the first pioneers of dental im-
plantology by developing a single-stage procedure, complete with immediate placement and immediate
loading of the implants used. These treatments are mainly performed with one-piece implants, as these
2 designs offer numerous advantages over two-piece implants in the context of immediate loading.
Dr. Werner Mander, Dr. Dr. (IMF Bukarest) Thomas Fabritius

Two different approaches to immediate loading of den-
tal implants are currently known. Both have in common
that splinting/stabilization of several implants is accom-
plished through the prosthetic superstructure (www.im-
plantfundation.org):
a The first approach relies on the compression screw
principle. Screw implants of this type can result in
lateral condensation of spongy areas. Implant stabil-
ity is greatly increased by a mechanism that could be
regarded as “corticalization” of the spongy bone.
b The second approach is to establish cortical anchor-
age of thin screw implants (bicortical screws, BCS) or
basal implants. Excellent primary stability can be ob-
tained along the vertical surfaces of these implants
with no need for corticalization. Implants of this type
are therefore well suited not only for immediate load-
ing but also for immediate placement.
Numerous publications have shown that ideal outcomes
can be achieved very easily and predictably with one-
piece screw implants (Figures 1 and 2) [Beckmann and
Beckmann 2005, Knöfler 2004]. This treatment approach
is relatively simple and minimally invasive, causing little
surgical trauma, carrying an extremely low risk of infec-
tion, and involving very low rates of implant loss. Another
strength is the possibility of immediate loading, which is
advantageous for obvious reasons and has been shown
to yield beneficial effects in maxillary molar areas.
///  Materials and Methods
A total of 678 KOS implants were placed to support
full-arch restorations in our office between 1997 and
2006. Each of the 89 patients involved was treated with
a metal-ceramic fixed complete denture in the maxilla
or mandible. Thus, 87 (97.7%) patients were available
for follow-up. All treatments were completed by per-
manent cementation of the definitive one-piece metal-
ceramic superstructure within 2 weeks of implant place-
ment. Some of the restorations also included natural
abutments.
The 89 full-arch restorations were supported by a mean
of 7.6 ± 2.3 implants and 2.0 ± 2.2 natural abutments
(Table 1). In the early years, we would allocate more time
(in some cases exceeding 2 weeks) for the technicians to
fabricate the restorations. Today we deliver the restora-
tions within 2 to 7 days of implant placement. Only in
extraction cases do we use a modified protocol, in order
to improve esthetic outcomes. Our policy in these cases
is to immediately insert a temporary restoration as usual
but to keep it as a long-term temporary restoration over
several months, until final recontouring of the hard and
soft tissue. Rather than placing KOS implants directly
into fresh extraction sockets, we rely on healed edentu-
lous sites near the socket. For placement into fresh ex-
traction sockets, we tend to use BCS implants. All screw
implants were transgingivally inserted under local anes-

Figure 1 Clinical view immediately after placement of 11 implants. Figure 2 Fixed complete denture 5 days after cementation.

DS 1/2 2009 www.FranzMedien.com


Table 1. Patient data and treatment details
Characteristics Mean ± SD
Age (years)
Follow-up (months)
Implants (per jaw)
Natural teeth (per jaw)
Gender (male)
Mixed restorations (teeth/implants)
Follow-up (n = 89)
*Two patients were lost to follow-up
thesia, which was immediately followed by temporary
restoration with a fixed complete denture. Surgery was
conducted in one session on an outpatient basis. Our
sample can be characterized as a single-center consecu-
tive case series. The mean age of patients was 58 ± 10.1
years. The youngest patient was 33 and the oldest pa-
tient 82 years old; 74 patients were male and 42 were fe-
male. The majority of 79.7% (n = 71) were non-smokers.
A mean of 2.0 ± 2.2 natural abutments could be included
in the fixed complete dentures, reflecting the presence
of usable residual teeth in 52 out of 89 patients/jaws.
Strictly edentulous jaws were restored in the remaining
37 patients, meaning that 41.6% of all fixed complete
dentures were supported by implants only (Table 1).
Table 3. Distribution of implant sites
Sites of implants (n = 678)
Maxilla
mandible
Anterior
Premolar/Molar
Tuberosity
Table 4. Survival rates based on natural abutment status,
maxilla/mandible and age
Success rates
anwenderbericht
Table 2. Distribution of implant types
Distribution of KOS types (n = 678)
Range
A = angulated 17%
B = flexible 67%
S = straight 16%
The follow-up of the study ranged between 1 month and
110 months (9.2 years) for a mean observation period of 3
34 months (2.83 years). Two patients (2.3%) were lost to
follow-up and could not be evaluated. The 678 compres-
sion screws used in the study fell into 67% KOS-B (flex-
ible), 17% KOS-A (angulated) and 16% KOS straight (Table
2, Figure 3). Maxillary implants accounted for 86% and
mandibular implants for 14%; 52% (n = 354) were placed
in anterior sites, compared to 42% (n = 283) in posterior
sites and 6% (n = 41) in tuberosity sites. A technique of
either motor-driven or manual implant placement into
tuberosity sites was developed relatively late into the
study. Before that time, we would normally refrain from
placing implants distal to the extended maxillary sinus.
Table 5. Failures broken down
by time periods
Failures
Table 6. Failures broken down by implant sites
(Losses: n = 29 or 4%)
www.FranzMedien.com DS 1/2 2009
 anwenderbericht
Figure 3 One-piece compression Figure 4 Change of primary stability by osteonal repair remodeling
screw implants (from: R. Bruce Martin, David B. Bur, Neil A. Shakey: Skeletal Tissue
(left to right: KOS, KOS A, KOS B). Mechanics; Springer 2004).
4
Instead, we would preferably use structures with a distal
cantilever in the first molar position.
This was possible because we would frequently insert an-
gulated KOS screws in the area of the second premolars
in order to avoid the maxillary sinus. At the same time, we
would place numerous implants anterior to each maxil-
lary sinus, thereby introducing high stability from the an-
terior segment to support the distal segments (Table 3).
A panoramic radiograph was obtained for each patient
and followed up by clinical examinations. The follow-up
examinations and outcome evaluations were conducted
in the same office as the initial treatments; they were,
however, not performed by the same clinician. The as-
sessments were made by the same dentists who also ana-
lyzed the panoramic radiographs to evaluate changes in
vertical bone levels.
///  Results
The overall survival rate of all KOS screw implants used
in this study was 95.7%. There was no significant dif-
ference between the fixed complete dentures sup-
ported by implants only (95.9%) and those also includ-
ing natural abutments (95.6%). Survival was a little, but
nevertheless significantly, lower for maxillary (95.5%)
than mandibular (97.9%) implants (Table 4). Broken up
by age groups, implant survival was 94% among pa-
tients 55 years or under, 94% among patients 55 to 65
years old, and 97% among patients older than 65 years
(Table 4).
Twenty-nine of the 678 implants failed. The rate of im-
plant failure was 4.3%. This percentage fell into 2.5% (n
= 17) early postoperative failures before cementation
of the definitive restoration and only 1.8% (n = 12) late
failures after definitive cementation (Table 5). Implant
fracture accounted for 3 failures (0.44%). One of these
events was caused by tooth loss underneath the fixed
restoration, while the other two fractures occurred in
KOS-B implants during tightening. Table 6 illustrates
the distribution of implant sites affected by the 29 fail-
ures. Failures were least common at site 14 (7.1% of all
implant losses) and most common at site 15 (18% of
all implant losses). Sites 13, 23, 25, and 26 demonstrat-
DS 1/2 2009 www.FranzMedien.com
ed identical failure rates
(10.7% of all implant loss-
es). Nine other sites were
affected by 1 implant loss
each, thus accounting for
roughly one-third of im-
plant failures (32.2%).
Twenty-two implants (3%)
were radiographically
shown to exhibit horizon-
tal or vertical bone loss
> 3 mm after placement.
These situations were as-
sociated with clinical evi-
dence of peri-implantitis.
///  Discussion
The cases followed up in the present study included
roughly the same number of implants in posterior (42% at
premolar and 6% at molar sites) an anterior (52%) jaw seg-
ments. The vast majority of implants (85%) were placed in
the maxilla (Table 3). The study was initially guided by the
principles of the First European Consensus Conference
[BDIZ 2006]. In accordance with these principles, the
distal segment of the maxilla was considered a risk area
for implant placement due to its poor bone quality. This
view was based on expert opinions and numerous stud-
ies [Attard and Zarb 2005, Becker et al. 2003, Bergkvist
et al. 2005, Derbabian and Simonian 2005]. It was main-
tained until the current consensus on immediate loading
was published [International Implant Foundation 2008].
However, our results demonstrate that immediate load-
ing is capable of yielding similarly high success rates even
at molar and premolar sites of the maxilla if certain prin-
ciples are observed, including immediate immobilization
of the implant abutments and definitive restoration with
simultaneous splinting of the implants with fixed cross-
arch dentures or at least 3 to 4 stable splinted abutments
in the same jaw segment no longer than 3 to 12 days af-
ter implant placement. On the subject of indications, it
should be noted that our patients’ desire for immediate
loading is an indication in its own right. Delayed proto-
cols should only be adopted if medical considerations ar-
gue against immediate loading. The present study dem-
onstrates that immediate loading is a viable option for
dental implants located virtually anywhere in the man-
dible or maxilla, provided that all relevant principles of
immediate loading are heeded and that enough implants
have been placed.
Our analysis of errors has revealed two critical
phases:
1. Early phase of temporization before delivery of the fi-
nal restoration (up to 12 days postoperatively)
2. Late phase after permanent cementation of the fi-
nal restoration (until complete bone healing; up to 6
months or even longer).

Early implant losses were mainly caused by:
• Poor bone quality leading to inadequate primary fric-
tion (< 30 Ncm).
• Fracture of temporary fixed denture.
• Premature insertion after tooth extraction (immature
bone is not readily identified during transmucosal
placement)
• Excessive loading of individual implants still con-
nected to a (temporary or final) restoration that has
become mobile upon temporary cementation.
It is essential for the success of immediate loading to con-
sider the time of bone regeneration. A truly safe period is
the early postoperative course ending on the third post-
operative day. This time window is followed by a phase
of highly active bone remodeling, which will carry an in-
creased risk for any prosthetic interventions (Figure 4).
The implants always need to be immobilized as quickly as
possible. In fact, we scarcely encountered any problems
even in numerous years of using delayed loading (e.g.
after 2 to 3 weeks). Presumably, this positive experience
can be attributed to corticalization along the compres-
sion thread, which would routinely lead to good primary
stability. In addition, osteonal structures are probably de-
stroyed as the bone is subjected to heavy local compres-
sion. Such bone could no longer be a departure point of
bone remodeling but could still be a potential endpoint
of bony pervasion. The onset of bone remodeling would
be delayed in corticalized areas. The safest path for clini-
cians, however, is to use temporary loading until the third
postoperative day, followed by continued service of the
first structure over at least 6 months (i.e. also in cases
of simultaneous tooth extractions). The entire second-
ary structure, whether definitive or temporary, should
be very firmly cemented by this ideal point in time (the
third day) for proper splinting and immobilization of the
recently placed implants, such that osseointegration can
progress smoothly. The phase of remodelation for bone
Figure 5 Bone levels after placement of 12 KOS implants in 1999.
Figure 6 Bone levels after 7 years in 2006 (same case as in Figure 5).
anwenderbericht
repair may take up to 6 months and, if the outlined con-
ditions are met, can proceed without complications. Any
mobility of the temporary restoration calls for immediate
recementation. To avoid this complication, numerous us-
ers will rightly employ strong permanent cements even in
the phase of temporization. A minority of patients would
present with hopeless conditions even for treatment with
thin 3-mm implants. Rather than subjecting these patients
to augmentation procedures ourselves, we referred them
to specialists for basal implantology or to colleagues with
a strong focus on bone augmentation. In our experience,
however, referrals of this type have been needed in 15%
of patients at the most. In all other 85% of patients for
whom major cross-arch fixed dentures were considered,
the transgingival KOS technique yielded optimal results
even in the absence of any laborious and risky reflection 5
or augmentation techniques. After all, these augmenta-
tion techniques are adjunctive surgical procedures and,
as such, will carry their own surgical risks. We took care
to select a treatment regimen avoiding procedures of this
type. Not a single patient in our office had to undergo
augmentation to create an implant bed.
We believe that the late implant losses after
definitive cementation were mainly caused by the
following factors:
1. Inadequate distance between implants (Figures 5 and
6). An enossal distance of 2 mm should be respected
with large-diameter KOS implants (4.1 or 5 mm). We
have not encountered any problems with thinner KOS
implants (even when placed very close to each other).
2. Fracture of an overly delicate metal framework.
3. Lesions of the bony implant bed caused by heat or ex-
cessive insertion pressure. These lesions were not im-
mediately evident but only occurred early in the study;
improvements in drill geometry and a torque-limiting
insertion technique largely eliminated this problem.
Figure 7 Postoperative view of slanted implants avoiding the maxillary
sinus (1999).
Figure 8 No visible bone loss, despite slanted implant insertion, after 9
years (same case as in Figure 7).
www.FranzMedien.com DS 1/2 2009
 anwenderbericht

Figure 9 Radiographic detail of Figure 10 Radiographic detail of

tuberosity site 18 in 2000 (same
case as Figures 7 and 8).
tuberosity site 18 (see Figure 9)
with evident bone apposition after
6 years.
Figure 12 Measuring pins used for verification in the OPG after pilot
drilling with BCD1/ DOS1. Implant cavities are checked for their correct
position relative to surrounding structures. The mucosal thickness in the
insertion area can be evaluated.

Figure 11 Planning of an overly delicate connector between crown Figure 13 Maxillary restoration after 6 years.
elements.

We did not observe any cases of implant failure caused by
excessive masticatory loading in the present study. This
finding indicates that our approach of splinting the su-
perstructures effectively minimized the pressure (Figures
7 and 8). Patterns of occlusion were usually adjusted to
long-centric designs with the possibility of gliding into
retral centric occlusion. Most patterns were adjusted to
group function rather than canine guidance. The maxil-
lary sinus could generally be avoided by slanted position-
ing of the implants.
Today we know that slanted insertion of dental implants
(relative to either the patient’s vertical axis or the bone
surface) with or in connection with delayed cross-arch
splinting will not create any disadvantages even in the
long run. In the presence of a balanced occlusion, slanted
insertion can even be associated with bone apposition
(Figures 9 and 10). From the very outset, great care must
be taken that the structure of the fixed denture will be
adequately thick to avoid fracture of the superstructure,
which is particularly true of zirconia frameworks (Figure
11). The present study demonstrates that few implants
(3%) are likely to show a reduction in vertical bone lev-
els with subsequent peri-implantitis. We believe that the
following two reasons account for this low complication
rate:
1. Small diameter of the polished implant neck, not ex-
ceeding 2.5 mm and even smaller in the flexible KOS-B
designs (1.8 mm).
2. One-piece implant design whose shape will preclude
any microgaps or micromovements between abut-
ments and implants.
///  Summary
This article reports on a retrospective study of 678 con-
secutively inserted KOS implants, which are one-piece
implants designed in accordance with the compression
screw principle. The study covers relatively long obser-
vation periods (of 33 months on average) and the great
number of restored jaws (n = 89). As a result, some highly
predictive conclusions can be drawn notably with regard
to immediate loading of these implants with cross-arch
structures:
1. High overall and long-term success rate of KOS im-
plants (95.7%) following transgingival insertion with-
out navigation.
2. High success rate in the maxilla (95.4% based on 582
implants, 48% of which were inserted at premolar or
molar sites).
3. Even higher success rate in the mandible (97.9 %).
4. Low failure rate irrespective of age.
5. Reduced incidence of vertical bone loss ≤ 3 mm (3%).
6. No prosthetic structures had to be replaced in their
entirety because of implant loss.
7. Concerning implant survival, there was no significant
difference between fixed dentures supported by im-
plants only and those also including natural abut-
ments.
Our experience with the KOS implant system, reflected in
the longitudinal analysis presented in this study, demon-
strate that KOS technology and the single-stage clinical
procedures developed with these compression implants
can offer unmatched long-term outcomes. We do not be-
lieve that navigated procedures to insert KOS implants

DS 1/2 2009 www.FranzMedien.com

 anwenderbericht
would hold any true advantages for experienced surgeons, although navigation can
be used to support the surgical protocol. Good results have been obtained with refer-
ence templates to create bleeding points for implant insertion and to perform mini-
mally invasive pilot drillings, which will permit adjustments in direction and depth
through the use of radiographic measuring pins. This is a very inexpensive and yet
highly reliable way to verify the success of implant placement (Figure 12). The tech-
nique can be used even in smaller offices and will eliminate the need for costly preop-
erative planning.
In very narrow ridges, KOS implants can also be inserted perfectly well, and without
any repercussions on the long-term success, by reflecting a mucoperiosteal flap. There
is no need to worry about side effects of flap reflection like the “regional acceleratory
phenomenon” (RAP) [Binderman et al., 2001; Yaffe et al., 1994]. After all, close proxim-
ity of both cortical walls has already been established in this situation. With very little
or no cancellous bone being left, the screw threads will end up bilaterally in cortical
bone structures not affected by the RAP. The presented technique has yielded the best
results in patients 65 to 82 years of age and therefore should be regarded the method 7
of choice precisely in this target group of patients (Table 4). As a consequence, splint-
type fixed complete dentures supported by KOS implants make sense particularly in
situations of aged atrophic bone as well as in largely edentulous mandibles and maxil-
lae. Patients under anticoagulation therapy are excellent candidates as well, thanks to
the minimally invasive approach. In many cases, anticoagulation does not even have
to be reduced after discussing the case with the patient’s general practitioner [Mander
and Sipos-Jackel 2007].

///  Conclusions
KOS implants are compression screws designed for single-stage procedures. They are
a cost-effective treatment alternative offering strong and lasting benefits in quality of
life. Immediate and long-term restorations can be implemented safely and with last-
ing success in a conveniently short time (Figure 13). Clinicians will find our preferred
treatment protocol very simple to perform, notably because the one-part implant de-
sign of the KOS system permits the use of abrasive instruments and impression-taking
very much like on natural teeth. Costly transfer elements are not mandatorily required.
Predictable outcomes can be obtained even in their absence, and the cost-benefit ra-
tio is excellent.

///  Editorial comment

This report is a short version of the findings obtained in the authors’ office study. You
may wish to contact the authors for an unabridged version with complete references.

Authors
Dr. Werner Mander
Rainerstrasse 36, 5310 Mondsee, Austria
w.mander@t-online.de
Dr. Dr. (IMF Bucharest) Thomas Fabritius
Traunring 96, 83301 Traunreut, Germany
info@zahnheilkunde-bayern.de

www.FranzMedien.com DS 1/2 2009